New vs. Established Patients

1. How does CMS define a patient as “new” versus “established”?
   
   Answer: In 2023, the definition of a “new” patient differs based on whether the patient is being treated in an office or an observation/ inpatient setting.
   
   In the observation and inpatient settings, services are considered initial for the provider or group when the patient has not received any services from a group member physician or NPP of the same specialty during the current observation and/or hospital stay.
   
   In the office setting, a patient is considered “new” to the provider or group when the patient has not received any services by a group member physician or NPP of the same specialty within the prior three-year period.
    
2. Drs. A and B were both members of a same-specialty practice that closed, and now both physicians join a new same-specialty practice with a new NPI. Patient Jones saw Dr. A at the original practice and, within a three year period of seeing Dr. A, now sees Dr. B during a first visit to the new practice.
   
   Please clarify whether Patient Jones is considered a new patient to the new practice and to Dr. B., since Dr. B was formerly in a same-specialty group with Dr. A.
   
   Answer: Dr. A and Dr. B are now members of a new practice, and their prior relationship as colleagues in the former practice is no longer in effect. If the patient sees Dr.B in the new practice, the patient is considered new to the practice and to Dr. B, who has not personally seen the patient before. If the patient had seen Dr.A in the new practice, the patient would have been considered established to Dr. A, who had personally seen the patient within the prior three years.
    
3. Please clarify appropriate billing for outpatient/office services when a consulting provider has already performed a service for the same patient in the inpatient or ED setting.
   
   Answer: ED services and initial inpatient care services are included within the three-year lookback period for billing new patient services in the outpatient/office setting. For example, a cardiologist may see a patient during a hospital stay and bill an initial inpatient care service (99221-99223), when the cardiologist subsequently sees the patient in the office setting, the office service would be billed in the range of 99212-99215.
    
4. A patient is seen in the ED by a resident and referred to another specialty provider. Is the patient considered “new” or “established” to the specialty provider?
   
   Answer: Care provided by a resident is not billable to Medicare and not counted in considering whether a patient is new to a Medicare provider seeing the patient for the first time. An initial office visit to a specialty practice would be considered a new patient visit, if the patient had not been seen by any same-specialty group practice member in the prior three years.
    
5. Does the concept of a “new patient” or “new problem” apply to patients treated in the ED?
   
   Answer: The concept of “new” vs. “established” patients does not apply in the ED. All ED patients, and their presenting problems, are considered as new, regardless of the patient’s history or the examiner’s prior experience with the patient.
    
6. Please clarify new patient visits and consultations in the office setting within a multi-specialty group practice.
   
   Answer: In multi-specialty office groups, when patients are seen for the first time by a group member of a different specialty, each specialist may bill a first encounter with the patient as a “new visit”. When group providers of the same specialty see a patient for the subsequent care, the patient is considered “established”, since the first encounter has been performed by a same-specialty colleague in the group.
    
7. Please explain the new vs. established patient rules for NPPs (PAs and NPPs) working in different specialty areas.
   
   Answer: NPs are designated by CMS as specialty 50, and PAs are designated as specialty 97. CMS, in consensus with AMA CPT, considers NPPs who are working with physicians as working in the exact same specialty or subspecialty as the physician. For example: a new patient visit by an NP working within internal medicine may be payable to the same group in which an NP working within cardiology has already been paid within three years. Additional information is required on NPP claims to allow these multiple first visits. When the additional information is not included on both claims, the second claim will deny and may be submitted as an appeal, with documentation of the first paid service along with the current service. Please refer to Nonphysician Practitioners – Reducing Costly Appeals; Increase Provider Revenue for NGS’ guidelines for NPP billing.
    
8. How does a plan for radiation therapy or chemotherapy affect the coding for the patient’s initial visit?
   
   Answer: Coding for an initial patient visit is based on the provider’s documentation of the patient’s history, the scope of physical examination and the medical decisions made as a result of the visit. Each of these elements must correlate to the level of detail that the provider finds medically necessary to address the patient’s problem(s). While chemotherapy and radiation therapy may increase the level of risk, all elements (history, exam, decision making) are included when selecting the correct coding for the service.
    
9. In a cardiology group, there are several specialty types (cardiology [06], electrophysiology [21] and interventional cardiology [C3]). If a patient has been seen as a “new” patient by one member of the group, how is a first visit with another group member billed, when the specialty type differs?
   
   Answer: As in all multi-specialty groups, when patients are seen for the first time by a group member of a different specialty, each specialist may bill a first encounter with the patient as a “new visit”. When group providers of the same specialty see a patient for the subsequent care, the patient is considered “established”, since the first encounter has been performed by a same-specialty colleague in the group.
    
10. If a provider who is credentialed with Medicare is starting to see patients at a new practice, and the patients were previously known to the provider from a prior practice, are these patients now considered to be “new” or “established” to the provider?
    
    Answer: If the provider has seen the patient within the prior three years, the patient is not new to the provider, who should be submitting claims for an established patient, regardless of which practice the patient is being seen in.
     
11. Inpatient professional billing (POS 21): If the hospitalist covering the oncology service performs and bills for an inpatient E/M visit and then asks for the medical oncologist to see the same patient, same day, can the medical oncologist also bill an E/M for his/her service?
    
    Answer: If the hospitalist’s specialty designation is different from the medical oncologist’s, then two E/M services may be payable. The medical necessity for both visits needs to be clearly indicated in the medical records.

Reviewed 10/8/2024